Revised 10/12/2011
Application for Donation of Mebendazole
Background
Children Without Worms (CWW) envisions the world's children free of intestinal parasites so they can grow, play, learn and enrich their communities. To achieve this vision, CWW works with Ministries of Health and Ministries of Education to administer deworming medication donated by Johnson & Johnson (J&J). CWW also advocates forhygiene education and increased access to water and sanitation facilities as part of acomprehensive strategy for reducing the global burden of soil-transmitted helminths (STH).
Beginning in January 2012, an expanded donation of 130 million doses of mebendazole (500 mg) will be available to governments supporting national STH control programs. The donations are intended for use to support mass drug administration campaigns targeting enrolled and non-enrolled school-age children at risk of STH.
This application will collect information to assess the applicant’s eligibility for the donated medicines based on demonstrated need for mebendazole (MEB), capacity to effectively and safely distribute MEB, and achieve sustained impact.
Review and Approval of Requests
Only applications from ministries of endemic countries will be considered. CWW’s Advisory Committee, an independent group of STH and global health experts, and the appropriate Regional Office of the World Health Organization (WHO) Neglected Tropical Disease (NTD) Department will evaluate all requests for donated MEB. Criteria for assessing requests include, but are not limited to: burden of disease, previous experience implementing deworming activities, opportunities to integrate with other child health interventions, and governmental support for deworming activities. Additional information regarding evaluation criteria is provided in Table 1.
Master Plans for Integrated Control of NTDs that have been approved by the Ministry of Health should be submitted along with the application form. If information requested in this application form is addressed in the Master Plan, please reference the requested information by providing on this form the specific section(s) and/or page numbers of the Master Plan.
Countries that are approved to receive donated drug may be asked to provide additional information regarding drug management. Countries are asked to sign the Undertaking at the end of this application, which states that the countries will allow MEB to be imported without tax or duty, will distribute MEB for the purposes intended, will monitor for and report any serious adverse experiences, have secured resources for the effective and safe distribution of donated MEB, and will comply with reporting requirements. The donations are long-term provided that recipient countries meet the conditions outlined in the Undertaking. Countries will be asked to provide campaign results and submit a reapplication form to qualify for continued donation of medicines for MDAs.
Table 1. Criteria for selecting recipient countries
Criteria / Demonstrated by /1. High disease burden / · Baseline intensity and prevalence surveys carried out in the last three years using guidelines of WHO
2. Resources committed by key stakeholders and funders, including the government / · Confirmed commitment from key stakeholder or funder, including the government
· Evidence of resources to implement a national STH control program, which includes distribution of MEB, training, social mobilization, and monitoring and evaluation activities
3. National ownership and commitment / · National Plan of Action for STH Control (criteria for acceptable plan of action to be established in collaboration with partners (e.g., WHO, USAID)
· Proportion of government resources (human and financial) committed to STH control
4. Partnerships for STH/NTD control / · National NTD Coordinating Committee that includes government ministries (e.g., MOH, MOE, Environment), NGOs, bilateral agencies, academia, and UN agencies
· NGOs should work in STH/NTD control
5. Safe and effective strategies for mass distribution / · Evidence of capability to implement comparable MDA campaigns
· Implementation strategies are outlined in Plan of Action
· High enrollment rate in primary schools or strategies for reaching out-of school children
6. Effective strategies for sustainability for STH control program / · WASH activities are included in Plan of Action
· Resources are secured for follow-up parasitological surveys
· % of population with access to water and sanitation facilities
7. Capacity to increase the scope of the STH control program as a result of receiving the donation / · Projected increase in the number of children to be treated
· Resources that would have been used for drug procurement are used to train teachers, and to carry out monitoring and evaluation activities
Applicants may be requested to submit additional information before final approval. Applicants will be notified of the Committee’s decision.
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Revised 10/12/2011
Please send a copy of the completed application and a cover letter from the responsible ministerial authority by postal mail, Email or facsimile to CWW and the appropriate WHO Regional Office.
Children Without WormsKim Koporc
Director
325 Swanton Way
Decatur
Georgia 30030
U.S.A.
Telephone: +1-404-687-5625
Facsimile: +1-404-371-1138
E-mail:
Internet: www.childrenwithoutworms.org / World Health Organization
African Regional Office (AFRO)
Dr. Adiele Onyeze
Programme Manager
Neglected Tropical Diseases
World Health Organization
Regional Office for Africa
P.O. Box 06
Djoue, Brazzaville
Congo
Telephone: +47 241 39161or
+242 057 710296
Facsimile: +47 241 39501
E-mail:
Internet: www.afro.who.int / World Health Organization
Eastern Mediterranean Regional Office (EMRO)
Dr. Riadh Ben-Ismail
Focal Point for Helminth Control
Abdul Razzak Al Sanhouri Street
P.O. Box 7608
Nasr Cit
Cairo 11371
Egypt
Telephone: +202 2670 2535
Facsimile: +202-2670 24 92/4
Email:
Internet: www.emro.who.int
WHO Regional Office for the Americas (AMRO)
Mr. Steven K. Ault
Focal Point for Helminth Control
525 Twenty-third Street, N.W. Washington, D.C. 20037
United States of America
Telephone: +1 (202) 974-3000
Fax: +1 (202) 974-3663
Email:
Internet: http://new.paho.org/ / WHO Regional Office for Europe (EURO)
Dr. Nedret Emiroglu
Focal Point for Helminth Control
Scherfigsvej 8
DK-2100 Copenhagen
Denmark
Telephone: +45 39171450
Email:
Internet: www.euro.who.int / WHO Regional Office for South East Asia (SEARO)
Prof. AP Dash (CDC)
Focal Point for Helminth Control
World Health House
Indraprastha Estate
Mahatma Gandhi Marg
New Delhi 110 002
India
Telephone: +91-11-23370804
Facsimile: +91-11-23370197
Email:
Internet: www.searo.who.int / WHO Regional Office for the Western Pacific (WPRO)
Dr. Eva Maria Christophel (acting)
Focal Point for Helminth Control
P.O. Box 2932
1000 Manila
Philippines
Telephone: +63 2 528 9991
Facsimile: +63 2 528 9069
Email:
Internet: www.wpro.who.int
Please direct any questions and/or comments to:
Ms. Kim Koporc
Director
Children Without Worms
Additional Information
Additional information about CWW can be found at www.childrenwithoutworms.org.
PLEASE NOTE:
The donation of MEB is intended for school-age children only
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Revised 10/12/2011
Application for Donation of Mebendazole
Submitted By
Country
Date Application Submitted (day/month/year)
Proposed Date for Drug Distribution (day/month/year)
Contents and Checklist
Section 1 – Provide background information regarding national STH control policies and contact information for key program personnel
Section 2 – Provide population and STH disease prevalence data
Section 3 – Describe national level commitment to the STH control program
Section 4 – Specify existing partnerships for the treatment and prevention of STH
Section 5 – Provide details on the mass drug distribution strategy
Section 6 – Describe plans for the sustainability of the STH control program
Section 7 – Specify implementation activities for STH control activities in 2011 and 2012
Section 8 – Provide contact information for consignee of donated MEB
Section 9 – Ensure the “Undertaking” is signed by the Ministry of Health
1. BACKGROUND INFORMATION
1.1. Is the treatment and prevention of STH infections included in the national health or school health policy?
Yes No If yes, please provide a copy of the policy document with this application.
1.2. Is there an intention to develop a Master Plan for the National Neglected Tropical Disease Program?
Yes No
Please specify the status of the Master Plan for the National Neglected Tropical Disease Programs.
____ Not started; projected start date: ______
____ Partially completed
____ Completed (If completed, please provide a copy with this application)
1.3. Is there a Program to Eliminate Lymphatic Filariasis in your country? Yes No
1.4 Please provide up-to-date contact information for the primary persons responsible for the receipt and management of donated drugs and implementation of STH control activities.
Contact information of individual completing form
Organization Name:Primary Contact:
Contact’s Dept. / Title:
Mailing Address:
Address a courier will deliver to:
Most reliable courier (e.g. DHL, FedEx):
Telephone:
Facsimile:
E-mail:
Contact information of government ministry responsible for the program for which MEB is being requested (if different from above)
Organization Name:Primary Contact:
Contact’s Dept. / Title:
Mailing Address:
Address a courier will deliver to:
Most reliable courier (e.g. DHL, FedEx):
Telephone:
Facsimile:
E-mail:
Contact information of the Medical Supervisor. The Medical Supervisor is responsible for assuring that sound medical practices are observed and treatment requirements are followed. He or she need not be physically present at all times but must be readily available for consultation (e.g., review of training materials and cases of serious adverse events). The Medical Supervisor must be a licensed physician. Public health experience, especially with STH control, is also desirable.
Organization Name:Primary Contact:
Contact’s Dept. / Title:
Mailing Address:
Address a courier will deliver to:
Most reliable courier (e.g. DHL, FedEx):
Telephone:
Facsimile:
E-mail:
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Revised 10/12/2011
2. DISEASE BURDEN
2.1 How many districts (i.e., implementation units) are there in your country? ______
2.2 In how many of these districts is STH a public health problem (i.e., prevalence is equal to or above 20%)? ______
2.3 Please complete the table below to provide an overview of the population, STH disease prevalence, and treatment coverage rates from the most recent deworming campaign. Specifically, please include only those districts in which your program would like to administer donated MEB. The districts selected for receipt of donated drugs should be those with documented evidence that STH is a public health problem.
a. Please provide the names of each district targeted for treatment with donated MEB by completing columns A and B of the following table.
b. Please provide population data for each district targeted for treatment by completing columns C and D (please use data from the most recent national population census).
c. Please provide primary school enrollment rates for each district by completing column E.
d. Provide percentage of total population with access to improved sanitation facilities by completing column F
e. Please provide STH prevalence data for each district targeted for treatment by completing columns G, H and I. If recent prevalence data are not available, data from published journal articles and older reports are acceptable. Additional sources of prevalence data for African countries include the WHO NTD Country Profiles[1] and the Global Atlas of Helminth Infections[2]. Please be sure to cite the source and year of the prevalence data.
f. Please indicate which districts are targeted by the Program to Eliminate Lymphatic Filariasis (PELF) and therefore, are receiving albendazole for the elimination of Lymphatic Filariasis by completing column J.
g. Please provide the year, total number and percent of school-age children treated for the most recent mass drug administration (MDA) campaigns carried out by completing column K.
(A)Larger Administrative Unit
(e.g., province, region, or state) / (B)
Smaller Administrative Unit
(e.g., district, prefecture, or LGA) / (C)
Total Population / (D)
Number of School-Age Children (5-14) Targeted for Treatment / (E)
Primary school Enrollment Rate / (F)
% Population with access to improved sanitation facilities / (G)
STH prevalence (%) / (H)
Source of prevalence data / (I)
Year of prevalence data / (J)
Participating in PELF
(yes/no) / (K)
History of MDA campaigns targeting school-age children /
Ascaris / Trichuris / Hookworm / Year of Last MDA / # Treated / % Treated / # of consecutive years MDA campaign reached 75 % /
Total
Please expand table if needed
2.4 Data Sources:
Please specify the source and year of the data referenced in the table above.
Source of population data (columns C& D): ______Year of population data (columns C&D): ______
Source of school enrollment data (column E): ______Year of school enrollment data (column E): ______
Source of sanitation coverage data (column F): ______Year of sanitation coverage data (column F): ______
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2.5 What criteria were used for selecting districts to receive donated MEB?
2.6 In the event that the number of doses of MEB donated is fewer than that requested, how will the STH Control Program prioritize districts to receive donated MEB?
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3. NATIONAL OWNERSHIP & COMMITMENT
3.1 Is there a National Coordinating Body overseeing STH control activities?
Yes No
If yes, please describe the structure and role of the National Coordinating body.
3.2 Please describe the technical resources provided by the national government for STH deworming and transmission control activities.
3.3 Please summarize the financial resources provided by the national government for STH deworming and transmission control activities. What proportion of the total budget is the government supporting?
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4. PARTNERSHIPS
4.1 Please list the names and roles of organizations responsible for STH deworming and transmission control activities. Please include support provided by bilateral agencies (e.g., DANIDA, JICA, USAID, DFID, EU), Government Ministries, NGOs, UN Agencies (e.g., UNICEF, WHO, WFP), and the World Bank.
Organization Name(s) / Organization Role(s) / Technical Resources Provided / Financial Resource Provided /Please expand table if needed
4.2 Please describe the agency or committee responsible for coordinating the activities of partner organizations with respect to STH control.
5. MASS DISTRIBUTION STRATEGIES
5.1 Please list the goals of the STH Control Program
5.2 Please list the objectives for each goal indicated above. Objectives should be measurable, time-bound and achievable.
5.3 Please describe the activities planned for achieving the stated objectives.
5.4 Please describe how the donation of MEB will lead to a net increase in the number of children dewormed AND enhance other components of STH control.
5.5 Please describe the mechanisms that will be used to distribute MEB (i.e., how will the distribution of MEB be carried out; describe other health programs that will be leveraged).